Systematic Review of Patient-Reported Outcomes following Surgical Treatment of Lymphedema

Lymphovenous Bypass for Immediate Lymphatic Reconstruction in Breast Cancer Patients Undergoing Axillary Lymph Node Dissection: Minimizing the Risk of Upper Extremity Lymphedema

BACKGROUND

 Studies have shown a significant reduction in breast cancer-related lymphedema (BCRL) rates in patients undergoing complete axillary lymph node dissection (cALND) combined with immediate lymphatic reconstruction (ILR) using lymphovenous bypass (LVB).The purpose of this study was to determine if ILR with LVB at the time of cALND results in a decreased incidence of BCRL and its impact on patient quality of life (QOL).

METHODS

 In this prospective cohort study, patients ≥ 18 years requiring cALND underwent ILR from 2019 to 2021. The primary outcome was bilateral upper limb volumes measured by Brørson's truncated cone formula and the Pero-System (3D Körper Scanner). The secondary outcome was QOL measured by the Lymphedema Quality of Life (LYMQOL) arm patient-reported outcome measurement.

RESULTS

 Forty-two patients consented to ILR using LVB. ILR was completed in 41 patients with a mean of 1.9 ± 0.9 lymphovenous anastomosis performed. Mean age of patients was 52.4 ± 10.5 years with a mean body mass index of 27.5 ± 4.9 kg/m2. All patients (n = 39, 100%) received adjuvant therapy after ILR. Mean follow-up was 15.2 ± 5.1 months. Five patients met criteria for lymphedema throughout the duration of the study (12.8%), with two patients having resolution, with an overall incidence of 7.7% by the end of the study period. Patients with lymphedema were found to have statistically significant lower total LYMQOL values at 18 months (8.44 ± 1.17 vs. 3.23 ± 0.56, p < 0.001). A mean increase of 0.73 ± 3.5 points was observed for overall QOL average for upper limb function at 18 months compared with 3 months (t = 0.823, p = 0.425).

CONCLUSION

 This study showed an incidence of 7.7% lymphedema development throughout the duration of study. We also showed that ILR has the potential to reduce the significant long-term adverse outcomes of lymphedema and improve QOL for patients undergoing cALND.

Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Upper Limb Lymphedema

Objectives: The LYMQOL is the most frequently translated, validated, objective tool for assessing Health-Related Quality of Life (HRQoL) in individuals with upper limb lymphedema (ULL). There have been adaptations and validations in a number of different countries. While a German version of LYMQOL Leg for lower limb lymphedema is available, a validated translation of LYMQOL Arm to German is lacking. We aimed to perform a cross-cultural adaption and translation according to ISPOR principles. Methods: Patients suffering from ULL from Germany, Austria, and Switzerland (n = 52) were questioned twice using the translated LYMQOL Arm, SF-36, and an evaluation questionnaire. The assessment of the content validity and face validity proved this version of LYMQOL Arm to be acceptable for interviewing German-speaking patients with ULL in Germany. Results: Comparison of LYMQOL Arm and SF-36 demonstrated good construct validity. Test-retest reliability was moderate to good (intraclass correlation coefficients 0.66-0.73). Cronbach's alpha values varied between 0.79 and 0.89 in both interviews, indicating good internal consistency. Factor analysis revealed a cumulative variance of 59.5% for the four domains of the questionnaire. Conclusion: There was no significant association between lymphedema stage and LYMQOL Arm score. This trial tested the appropriateness of the German version of the LYMQOL Arm for measuring HRQoL in German-speaking individuals with ULL.

Current diagnostic and quantitative techniques in the field of lymphedema management: a critical review

Lymphedema evaluation entails multifaceted considerations for which options continue to evolve and emerge. This paper provides a critical review of the current status of diagnostic and quantitative measures for lymphedema, from traditional and novel bedside assessment tools for volumetric and fluid assessment, to advanced imaging modalities. Modalities are contrasted with regard to empirical support and feasibility of clinical implementation. The manuscript proposes a grid framework for comparing the ability of each modality to quantify specific lymphedema characteristics, including distribution, dysmorphism, tissue composition and fluid content, lymphatic anatomy and function, metaplasia, clinical symptoms, and quality of life and function. This review additionally applies a similar framework approach to consider how well assessment tools support important clinical needs, including: (1) screening, (2) diagnosis and differential diagnosis, (3) individualization of treatment, and (4) monitoring treatment response. The framework highlights which clinical needs are served by an abundance of assessment tools and identifies others that have problematically few. The framework clarifies which tools have greater or lesser empirical support. The framework is designed to assist stakeholders in selecting appropriate diagnostic and surveillance modalities, gauging levels of confidence when applying tools to specific clinical needs, elucidating overarching patterns of diagnostic and quantitative strengths and weaknesses, and informing future investigation.

Demonstrating the benefit of a cellulitis-specific patient reported outcome measure (CELLUPROM©) as part of the National Cellulitis Improvement Programme in Wales

PURPOSE

Despite a known risk of cellulitis recurrence, the management of the wider impact and risk factors has been neglected. The innovative National Cellulitis Improvement Programme (NCIP) addresses this by providing evidence-based and individualised care to improve patient reported outcomes and reduce the risk of recurrence. The aim of this paper is to examine the longer-term impact of cellulitis and to identify a suitable and clinically relevant Patient Reported Outcome Measure (PROM).

METHODS

A review of existing cellulitis-specific PROMs was undertaken, alongside literature detailing the patient-focused impact of cellulitis, to identify a suitable PROM for clinical use. A group of expert therapists and patient representatives (n = 14) shared their individual and collective experiences over a series of events to discuss and debate the impact of cellulitis and review available PROMs. CELLUPROM© is introduced with anonymised PROM data and case study information reported to establish the impact of CELLUPROM© within usual NCIP care.

RESULTS

No cellulitis-specific PROMs were identified. Literature focused on the signs and symptoms of an acute episode of cellulitis, with outcome measures primarily used to evidence the impact of an intervention. An enduring physical, social and emotional impact of cellulitis was identified in this study, providing the basis for the new cellulitis-specific PROM (CELLUPROM©), which has been implemented with good effect in clinical care.

CONCLUSION

This study has highlighted the lasting impact of cellulitis. Using CELLUPROM© within the risk-reduction NCIP has helped develop Value-Based Healthcare and support programme evaluation.

We Are Not Speaking the Same Language: Current Procedural Terminology Coding and Provision of Care in Lymphatic Reconstruction

INTRODUCTION

Current Procedural Terminology (CPT) codes provide a uniform language for medical billing, but specific codes have not been assigned for lymphatic reconstruction techniques. The authors hypothesized that inadequate codes would contribute to heterogeneous coding practices and reimbursement challenges, ultimately limiting surgeons' ability to treat patients.

METHODS

A 22-item virtual questionnaire was offered to 959 members of the American Society of Reconstructive Microsurgeons to assess the volume of lymphatic reconstruction procedures performed, CPT codes used for each procedure, and challenges related to coding and providing care.

RESULTS

The survey was completed by 66 board-certified/board-eligible plastic surgeons (6.9%), who unanimously agreed that lymphatic surgery is integral to cancer care, with 86.4% indicating that immediate lymphatic reconstruction should be offered after lymphadenectomy. Most performed lymphovenous bypass, immediate lymphatic reconstruction, liposuction, and vascularized lymph node transfer.Respondents reported that available CPT codes failed to reflect procedural scope. A wide variety of CPT codes was used to report each type of procedure. Insurance coverage problems led to 69.7% of respondents forgoing operations and 32% reducing treatment offerings. Insurance coverage and CPT codes were identified as significant barriers to care by 98.5% and 95.5% of respondents, respectively.

CONCLUSIONS

Respondents unanimously agreed on the importance of lymphatic reconstruction in cancer care, and most identified inadequate CPT codes as causing billing issues, which hindered their ability to offer surgical treatment. Appropriate and specific CPT codes are necessary to ensure accuracy and consistency of reporting and ultimately to improve patient access to care.

Surgical Treatment of Breast Lymphedema: A Distinct Pathology With Unique Challenges

BACKGROUND

Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical treatment for breast lymphedema (BL) are sparse, consisting of case reports and almost exclusively LVB. We report our experience with BL, including a case of mastectomy and breast reconstruction with abdominal free flap and inguinal vascularized lymph node transfer (VLNT) for BL. We compare our series with the surgical literature to discern unique characteristics and treatment limitations inherent to this disease.

METHODS

A database was prospectively maintained from September 2020 to May 2023 including all patients diagnosed with BL who were referred to our institution. Breast lymphedema was diagnosed using clinical criteria, and relevant patient data were recorded. Patients interested in surgical management underwent indocyanine green lymphography to determine candidacy for LVB or other interventions. All patients, including those surgically managed, were treated with complex decongestive therapy.

RESULTS

Nine patients with BL were included. Eight had undergone breast-conserving therapy for breast cancer with whole breast irradiation. One patient was treated for Hodgkin lymphoma with axillary lymphadenectomy and axillary radiation. Indocyanine green lymphography was performed in 6 patients, of which 4 patients had diffuse dermal backflow. Two patients had lymphatic targets suitable for LVB, including the patient without breast irradiation. Three patients were managed surgically. One patient without bypass targets underwent breast reduction with partial symptomatic relief, later followed by a mastectomy with abdominal free flap reconstruction and VLNT. Two patients with suitable bypass targets underwent LVB, with resolution of breast swelling and subjective symptoms.

CONCLUSIONS

The diffuse lymphatic obliteration due to radiation field effect in BL results in a distinct pathophysiology compared with extremity lymphedema. Although published reports of surgical BL treatment almost exclusively describe LVB, other surgical options may be more frequently required. Ablative strategies such as mastectomy and regenerative techniques such as VLNT should be considered potential first-line treatment options for these patients.

Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL)

PURPOSE

Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).

METHODS

A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.

RESULTS

A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.

CONCLUSIONS

Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Impact of neoadjuvant chemotherapy on breast cancer-related lymphedema after axillary lymph node dissection: a retrospective cohort study

PURPOSE

We aimed to evaluate whether neoadjuvant chemotherapy (NAC) could be a risk factor for breast cancer-related lymphedema (BCRL) associated with axillary lymph node dissection (ALND).

PATIENTS AND METHODS

A total of 596 patients with cT0-4N0-3M0 breast cancer who underwent ALND and chemotherapy were retrospectively analyzed between March 2012 and March 2022. NAC was administered in 188 patients (31.5%), while up-front surgery in 408 (68.5%). Univariate and multivariable Cox regression analyses were performed to determine whether NAC was an independent risk factor for BCRL. With propensity score matching (PSM), the NAC group and up-front surgery group were matched 1:1 by age, body mass index (BMI), molecular subtypes, type of breast surgery, and the number of positive lymph nodes. Kaplan-Meier survival analyses were performed for BCRL between groups before and after PSM. Subgroup analyses were conducted to explore whether NAC differed for BCRL occurrence in people with different characteristics.

RESULTS

At a median follow-up of 36.3 months, 130 patients (21.8%) experienced BCRL [NAC, 50/188 (26.60%) vs. up-front surgery, 80/408 (19.61%); P = 0.030]. Multivariable analysis identified that NAC [hazard ratio, 1.503; 95% CI (1.03, 2.19); P = 0.033] was an independent risk factor for BCRL. In addition, the hormone receptor-negative/human epidermal growth factor receptor 2-negative (HR-/HER2-) subtype, breast-conserving surgery (BCS), and increased positive lymph nodes significantly increased BCRL risk. After PSM, NAC remained a risk factor for BCRL [hazard ratio, 1.896; 95% CI (1.18, 3.04); P = 0.007]. Subgroup analyses showed that NAC had a consistent BCRL risk in most clinical subgroups.

CONCLUSION

NAC receipt has a statistically significant increase in BCRL risk in patients with ALND. These patients should be closely monitored and may benefit from early BCRL intervention.

Psychological Changes During Inpatient Conservative Treatment for Lymphedema

Background: Learning self-care for lymphedema is essential for patients to maintain their quality of life; however, it is sometimes difficult and stressful. There are only few studies about the psychological changes in patients hospitalized for conservative therapy. The purpose of this study was to evaluate the psychological changes in patients admitted for conservative therapy and training in self-care for lymphedema. Methods and Results: Nine patients who were hospitalized for conservative treatment of lymphedema of the lower limbs were administered the Profile of Moods States questionnaire twice: day of admission or the following day and after 5 days of hospital stay. Eight female patients and one male patient were included in this retrospective study. The mean age was 67.2 years. We provided standard compression therapy, manual lymph drainage, and exercise therapy to the patients. The Profile of Moods States 2nd edition, Japanese version of the Profile of Moods States, was used as an evaluation method of the psychological state. The results of the psychological tests were evaluated by a certified public psychologist. The scores for negative mood (anger or hostility, confusion or bewilderment, depression or rejection, fatigue or inertia, and tension and anxiety) were all lower on the fifth day of hospitalization compared with those at admission. In particular, the tension or anxiety scores decreased significantly (p = 0.019). However, the vigor or activity scores tended to increase. Conclusions: It was found that inpatient conservative therapy for lymphedema had a positive effect on the psychological state of the patients. Despite stressors such as a change in environment and introduction of new treatments (compression therapy and exercise therapy), the improvement in edema helped elevate the mood of the patients by the fifth day of hospitalization.

Demystifying vascularized lymph node transfers and lymphatico-venous anastomoses

Lymphedema continues to be a widely prevalent condition with no definitive cure. It affects a wide range of patients across different ages and backgrounds. The significant burden of this chronic and debilitating condition necessitates more research and comprehensive healthcare coverage for affected patients. In developed countries, cancer survivors are disproportionality affected by this condition. Risk factors including lymph node dissections and radiation render many cancer patients more susceptible to the development of lymphedema. Part of the challenge with lymphedema care, is that it exits on a broad spectrum with significant variability of symptoms. Advances and broader availability of various imaging modalities continue to foster progress in lymphedema surgery. The conservative management of lymphedema remains the primary initial management option. However, lymphedema surgeries can provide significant hope and may pave the way for significant improvements in the quality-of-life for many patients afflicted by this progressive and enfeebling condition. Reductive and physiologic procedures are becoming an important part of the armamentarium of the modern plastic and reconstructive surgeon. Recent advances in physiologic lymphedema surgeries are accelerating their transition from experimental surgeries to broadly adopted and widely accepted procedures that can lead to major successes in the fight against this condition. Prophylactic lymphedema surgery also presents a promising choice for many patients and can help prevent lymphedema development in high-risk patients.

PPARγ agonist treatment reduces fibroadipose tissue in secondary lymphedema by exhausting fibroadipogenic PDGFRα+ mesenchymal cells

Secondary lymphedema occurs in up to 20% of patients after lymphadenectomy performed for the surgical management of tumors involving the breast, prostate, uterus, and skin. Patients develop progressive edema of the affected extremity due to retention of protein-rich lymphatic fluid. Despite compression therapy, patients progress to chronic lymphedema in which noncompressible fibrosis and adipose tissue are deposited within the extremity. The presence of fibrosis led to our hypothesis that rosiglitazone, a PPARγ agonist that inhibits fibrosis, would reduce fibrosis in a mouse model of secondary lymphedema after hind limb lymphadenectomy. In vivo, rosiglitazone reduced fibrosis in the hind limb after lymphadenectomy. Our findings verified that rosiglitazone reestablished the adipogenic features of TGF-β1-treated mesenchymal cells in vitro. Despite this, rosiglitazone led to a reduction in adipose tissue deposition. Single-cell RNA-Seq data obtained from human tissues and flow cytometric and histological evaluation of mouse tissues demonstrated increased presence of PDGFRα+ cells in lymphedema; human tissue analysis verified these cells have the capacity for adipogenic and fibrogenic differentiation. Upon treatment with rosiglitazone, we noted a reduction in the overall quantity of PDGFRα+ cells and LipidTOX+ cells. Our findings provide a framework for treating secondary lymphedema as a condition of fibrosis and adipose tissue deposition, both of which, paradoxically, can be prevented with a pro-adipogenic agent.

The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients

Background  This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods  The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results  The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p  < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p  < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p  = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p  = 0.659, r  = - 0.041), and amount of limb volume reduction ( p  = 0.454, r  = - 0.070) showed no statistical significance. Conclusion  The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.

Effectiveness of routine provision of feedback from patient-reported outcome measurements for cancer care improvement: a systematic review and meta-analysis

BACKGROUND

Research shows that feeding back patient-reported outcome information to clinicians and/or patients could be associated with improved care processes and patient outcomes. Quantitative syntheses of intervention effects on oncology patient outcomes are lacking.

OBJECTIVE

To determine the effects of patient-reported outcome measure (PROM) feedback intervention on oncology patient outcomes.

DATA SOURCES

We identified relevant studies from 116 references included in our previous Cochrane review assessing the intervention for the general population. In May 2022, we conducted a systematic search in five bibliography databases using predefined keywords for additional studies published after the Cochrane review.

STUDY SELECTION

We included randomized controlled trials evaluating the effects of PROM feedback intervention on processes and outcomes of care for oncology patients.

DATA EXTRACTION AND SYNTHESIS

We used the meta-analytic approach to synthesize across studies measuring the same outcomes. We estimated pooled effects of the intervention on outcomes using Cohen's d for continuous data and risk ratio (RR) with a 95% confidence interval for dichotomous data. We used a descriptive approach to summarize studies which reported insufficient data for a meta-analysis.

MAIN OUTCOME(S) AND MEASURES(S)

Health-related quality of life (HRQL), symptoms, patient-healthcare provider communication, number of visits and hospitalizations, number of adverse events, and overall survival.

RESULTS

We included 29 studies involving 7071 cancer participants. A small number of studies was available for each metanalysis (median = 3 studies, ranging from 2 to 9 studies) due to heterogeneity in the evaluation of the trials. We found that the intervention improved HRQL (Cohen's d = 0.23, 95% CI 0.11-0.34), mental functioning (Cohen's d = 0.14, 95% CI 0.02-0.26), patient-healthcare provider communication (Cohen's d = 0.41, 95% CI 0.20-0.62), and 1-year overall survival (OR = 0.64, 95% CI 0.48-0.86). The risk of bias across studies was considerable in the domains of allocation concealment, blinding, and intervention contamination.

CONCLUSIONS AND RELEVANCE

Although we found evidence to support the intervention for highly relevant outcomes, our conclusions are tempered by the high risk of bias relating mainly to intervention design. PROM feedback for oncology patients may improve processes and outcomes for cancer patients but more high-quality evidence is required.

Ensuring patient centeredness in upper extremity lymphedema research: Identifying patient-prioritized agenda and preferences

PURPOSE

To elicit a patient-prioritized agenda and preferences for upper extremity lymphedema (LE) research.

METHODS

Focus group sessions (FGs) were conducted with English-speaking, adult women (18 years and older) with breast cancer-related LE (BCRL) seeking conservative or surgical care at two tertiary cancer centers in Ontario, Canada. An interview guide was used; women were asked to describe health-related quality of life (HRQL) outcomes that mattered the most to them, followed by their preferences for research study design and for providing patient-reported outcomes measure (PROM) data. Inductive content analysis was used to identify themes and subthemes.

RESULTS

A total of 16 women participated in 4 FG sessions (55 ± 9.5 years) and described the impact of LE on their appearance, physical, psychosocial, and sexual well-being. Women emphasized that psychosocial well-being was often not discussed in clinical care and that they were poorly informed of LE risk and care options. Most women said that they would not be willing to be randomized to surgical versus conservative management of LE. They also expressed a preference to complete PROM data electronically. All women emphasized the value of having an open text option alongside PROMs to expand on their concerns.

CONCLUSION

Patient centeredness is key to generating meaningful data and ensuring ongoing engagement in clinical research. In LE, comprehensive PROMs that measure a range of HRQL concerns, especially psychosocial well-being, should be considered. Women with BCRL are reluctant to be randomized to conservative care when a surgical option is available, resulting in implications for planning trial sample size and recruitment.

Psychometric evaluation of the Chinese version of the Upper Limb Lymphedema Quality of Life Questionnaire in breast cancer-related lymphedema patients

PURPOSE

The purpose of this study was to translate and evaluate the psychometric properties of the Chinese version of the Upper Limb Lymphedema Quality of Life Questionnaire (C-ULLQoL).

METHODS

Eighty-five participants completed the C-ULLQoL and the Functional Assessment of Cancer Therapy-Breast (C-FACT-B). The Cronbach's alpha (α) was used to determine the internal consistency, and intraclass correlation coefficients (ICCs) - to evaluate the test-retest reliability. The content validity index (CVI) was assessed by a group of experts. Construct validity was examined by performing factor analysis and criterion validity by observing the correlations between C-ULLQoL with C-FACT-B.

RESULTS

Cronbach's α of the total scale was 0.930. ICC scores ranged from 0.874 to 0.938. The content validity of C-ULLQoL was acceptable. Two factors (65.488% of the variance) were extracted by exploratory factor analysis. A significant correlation was observed between C-ULLQoL and C-FACT-B (r = -0.611, p < 0.01).

CONCLUSION

The C-ULLQoL is a reliable and valid questionnaire that can be used in clinic and scientific practice for evaluating health-related quality of life in Chinese patients with breast cancer-related lymphedema.IMPLICATIONS FOR REHABILITATIONAn effective and comprehensive scale to measure the health-related quality of life (HRQoL) is essential because breast cancer-related lymphedema (BCRL) leads to various complications for patients, caregivers, and society.The Chinese version of the Upper Limb Lymphedema Quality of Life Scale (C-ULLQoL) is a valid, reliable, and practical instrument to comprehensively assess HRQoL in Chinese patients with BCRL.The C-ULLQoL can be used in both clinical and research settings to evaluate HRQoL of BCRL patients in China.

Combining reconstructive and ablative surgical treatment of chronic breast cancer-related lymphedema (BCRL): safe and effective

PURPOSE

We investigated whether a one-stage combination of vascularized lymph node transfer (VLNT) with water jet-assisted liposuction (WAL) can be safely performed and results in improved patient outcomes such as a greater reduction in arm volume when treating chronic breast cancer-related lymphedema (BCRL).

METHODS

In this retrospective cohort study, we included all patients from our encrypted lymphedema database treated for chronic BCRL with VLNT or VLNT + WAL who had a minimum follow-up of two years. We analyzed patient-specific variables including arm circumferences as well as patient-reported outcomes before and after surgery as well as surgery time, surgery-related complications and patient satisfaction.

RESULTS

Only the mean preoperative differences of the circumferences between the lymphedematous and the unaffected arm in individual patients showed a statistically significant difference between treatment groups (p < 0.05). Indeed, patients treated with VLNT + WAL had consistently larger differences in individual sets of arms and therefore more pronounced chronic BCRL. The mean surgery time was significantly longer in the VLNT + WAL group (p < 0.05). Complications were seldom and similar in both groups. Using a numeric rating scale, the level of patient satisfaction following treatment did not differ significantly between groups (p = 0.323).

CONCLUSIONS

Our findings suggest that a one-stage combination of VLNT with WAL does not result in more complications even though it also entails a longer surgery time. This is acceptable as secondary interventions resulting in overall longer surgery times and higher costs can be avoided. A one-stage combination might be especially favourable for patients suffering from more severe chronic BCRL.

Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review

Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients.

METHODS

A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes.

RESULTS

A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL.

CONCLUSIONS

LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.

Five decades of progress in surgical oncology: Breast

Surgery remains the single most effective treatment for breast cancer but coincident with a deeper understanding of tumor biology and advances in multidisciplinary care (encompassing breast imaging, systemic adjuvant therapy, radiotherapy, and genomics) continues to de-escalate, supported by strong level I data. We have moved from mastectomy to breast conservation, and from routine axillary dissection to sentinel lymph node biopsy to selective omission of axillary node staging altogether. We have further de-escalated through consensus over margin width in breast conservation, through improvements in neoadjuvant therapy, and by demonstrating no benefit for upfront surgery in patients with stage IV disease. For patients with ipsilateral breast tumor recurrence, reconservation surgery and reirradiation are promising. Cell cycle and immune checkpoint inhibitors, when added to conventional systemic therapy, have now moved beyond stage IV disease to phase III trials in the adjuvant and neoadjuvant settings, promising even further de-escalation of surgery. Finally, with genomic profiling we are moving away from the primacy of axillary node status for prognostication and into a new era allowing prediction of response to therapy.

Evaluation of Circulating MicroRNAs and Adipokines in Breast Cancer Survivors with Arm Lymphedema

Breast cancer-related lymphedema (BCRL) is a form of secondary lymphedema that is characterized by abnormal swelling of one or both arms due to the accumulation of lymph fluid in the interstitial tissue spaces, resulting from obstruction of the lymphatic vessels due to surgery insults, radiotherapy, or chemotherapy. Due to the multifactorial nature of this condition, the pathogenesis of secondary lymphedema remains unclear and the search for molecular factors associated with the condition is ongoing. This study aimed to identify serum microRNAs and adipokines associated with BCRL. Blood was collected from 113 breast cancer survivors and processed to obtain serum for small RNA-sequencing (BCRL vs. non-BCRL, n = 7 per group). MicroRNAs that were differentially expressed (fold change >1.5, p < 0.05) between lymphedema cases and those without lymphedema were further quantified in a validation cohort through quantitative reverse transcription PCR (BCRL n = 16, non-BCRL, n = 83). Leptin and adiponectin levels were measured in a combined cohort (BCRL n = 23, non-BCRL n = 90) using enzyme-linked immunosorbent assays. Two of the most significantly upregulated microRNAs, miR-199a-3p and miR-151a-3p, were strongly correlated with the onset of lymphedema and diabetes mellitus in the BCRL group. Leptin levels were higher in the BCRL cohort compared to the non-BCRL cohort (p < 0.05). A metabolic syndrome biomarker, the adiponectin/leptin ratio, was found to be lower in the BCRL group than in the non-BCRL group (median: 0.28 vs. 0.41, p < 0.05). Extensive studies on the mechanisms of the identified microRNAs and association of leptin with arm lymphedema may provide new insights on the potential biomarkers for lymphedema that should be followed up in a prospective cohort study.

Reliability and validity testing of the Korean translation of lymphedema quality of life questionnaire (LYMQOL) for lower limb lymphedema

PURPOSE

This study aimed to translate the Lymphedema Quality of Life Questionnaire-leg into Korean (K-LYMQOL-leg) and test its reliability and validity.

MATERIALS AND METHODS

The LYMQOL-leg was translated forward and backward from English to Korean. Fifty-five patients with lower limb lymphedema completed the K-LYMQOL-leg and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-C30) at the first visit, and the K-LYMQOL-leg was re-administered within a week. Reliability was tested by calculating the intraclass correlation coefficient (ICC) and the Cronbach's alpha for each domain. Face validity was evaluated, and concurrent validity was verified by comparing the K-LYMQOL-leg domain scores with the corresponding EORTC-QLQ-C30 and limb volume scales. The known-group construct validity was then assessed.

RESULTS

Excellent reliability was confirmed by internal consistency (Cronbach's alpha coefficient, 0.851-0.878) and test-retest reliability (ICC, 0.901-0.936) in the four domains. A significant correlation was confirmed in the appearance domain with limb volume (r = 0.424) and in the other domains [function, symptom, and mood], with the EORTC-QLQ-C30 scales (r = -0.779, 0.712, and -0.783). Known-group validity was confirmed in all four domains.

CONCLUSIONS

The K-LYMQOL-leg verified in this study can be used in clinical practice to evaluate the Quality of Life (QOL) of patients with lymphedema or in research as an outcome.IMPLICATIONS FOR REHABILITATIONAmong cancer treatment-related complications, lymphedema of the lower extremities severely and persistently reduces the health-related quality of life of cancer survivors.The Korean version of the Lymphedema Quality of Life Questionnaire-leg (K-LYMQOL-leg) is an easy, reliable and valid questionnaire for patients with lower limb lymphedema.K-LYMQOL-leg will be useful in assessing the quality of life of patients with lower limb lymphedema in a clinical setting or for research purposes.

Reliability and Validity of the Korean Version of the Lymphedema Quality of Life Questionnaire in Breast Cancer-Related Lymphedema Patients

Background: This study aimed to demonstrate the reliability and validity of the Korean version of the Lymphedema Quality of Life (LYMQOL) questionnaire. Methods and Results: This study was a multicentered cross-sectional survey of patients with breast cancer-related lymphedema. The LYMQOL-arm questionnaire was translated from English to Korean. This 28-item instrument contains the overall quality of life (QOL) and is categorized into four domains: function, appearance, symptoms, and mood. In addition, the demographics and characteristics of lymphedema were assessed by reviewing the medical records. The LYMQOL-arm, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), and Breast Cancer Module 23 (EORTC QLQ-BR23) were administered. The internal consistency of the LYMQOL-arm was analyzed using Cronbach's α, and test-retest reliability was examined using the intraclass correlation coefficient (ICC). Concurrent validity was evaluated using Pearson's correlation test between the LYMQOL-arm and the EORTC QLQ instruments. A total of 62 participants were enrolled in the study. All domains of the LYMQOL-arm showed high internal consistency, and the ICC of each domain and overall QOL ranged from 0.836 to 0.956 (p < 0.001). All domains and overall QOL scores of the LYMQOL-arm significantly correlated with most of the EORTC QLQ-C30 and EORTC QLQ-BR23 scales. Furthermore, it revealed a significant association with the degree of perceived edema. Conclusions: The Korean version of the LYMQOL-arm questionnaire has proven its reliability and validity in assessing QOL in patients with breast cancer-related lymphedema.

Dutch translation and cultural adaptation of the LYMPH-Q, a new patient-reported outcome measure for breast cancer-related lymphedema

Background

The LYMPH-Q Upper Extremity module is a new patient-reported outcome measure (PROM) developed to assess patient outcomes of breast cancer-related arm lymphedema (BCRL). Content for the LYMPH-Q Upper Extremity Module was developed from the extensive input of patients and experts in the field of breast surgery and breast cancer-related lymphedema. Rasch Measurement Theory analysis was used to assess psychometric properties. The aim of this study was to perform a Dutch translation and cultural adaptation of the LYMPH-Q Upper Extremity Module.

Methods

The translation process was performed in accordance with the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).The process included two forward translations, two back translations, and cognitive debriefing interviews with patients with BCRL.

Results

Comparison of the two forward translations showed that the translations for most items (n = 60; 88.2%) were conceptually consistent between the two translators. Translations of the remaining items were reviewed and discussed until consensus was reached. Three items in the back translation had a different meaning when compared to the original English version and required re-translation. The resultant Dutch version of the LYMPH-Q was tested in a series of cognitive debriefing interviews with seven patients and showed good content validity.

Conclusions

The translation and cultural adaptation process resulted in a conceptually equivalent Dutch version of the LYMPH-Q Upper Extremity Module. This new PROM can now be used in clinical practice and research settings to evaluate outcomes in patients with BCRL.

Level of evidence: Not gradable

Quality of life improvement in breast cancer survivors affected by upper limb lymphedema through a novel multiperspective physical activity methodology: a monocentric pilot study

PURPOSE

Chronic lymphedema causes psychophysical sequelae jeopardizing quality of life (QoL) of breast cancer (BC) survivors, and lack of effective therapies represents a major challenge for healthcare professionals. Structured adapted physical activity (APA) may represent an effective strategy to attenuate cancer treatment-related impairments and improve QoL. Here, we describe the effects of a specific APA intervention based on a novel multiperspective methodology in counteracting lymphedema-related morphofunctional alterations and improving QoL of BC survivors.

METHODS

BC survivors with chronic moderate/severe lymphedema attending the Cancer Rehabilitation Center in Florence were assessed before and after 8-week APA. The protocol consisted of both APA specialist-supervised and self-leaded sessions using a tailor-designed proprioceptive board. Body mass index, bioimpedance parameters, indirect upper limb volume measurement, and ultrasonography were performed. Wrist flexion/extension and hand strength functional tests were also executed. QoL, depression/anxiety and pain intensity were evaluated by ULL27, HADS, distress thermometer and NRS questionnaires, respectively.

RESULTS

Although bioimpedance, ultrasound and volumetric measures remained mostly unchanged, wrist mobility, pain perception, depression, and QoL were all significantly ameliorated after APA.

CONCLUSIONS

Our findings suggest that a multidisciplinary treatment approach involving APA professionals should be employed in the management of BC-related lymphedema to improve patient psychophysical outcomes and QoL.

Severe lymphoedema in gynaecological cancers: Impact of pneumatic compression on quality of life

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Lower limb lymphoedema adversely affects quality of life in gynaecological cancer patients.

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Pneumatic compression devices facilitate home self-management of severe lymphoedema.

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Significant improvement across all quality of life domains except sexual function was achieved.

Objective

Good survival rates from gynaecological cancers focus our attention on the quality of survivorship. Lymphoedema is a common complication that affects many aspects of quality of life (QOL). We undertook a prospective audit of QOL of patients with higher grade lymphoedema using home compression pneumatic devices. The aim of this study was to assess QOL in a mixed gynaecological cancer cohort before and after at least eight weeks of home compression treatment.

Methods

Thirteen patients with the most severely disabling lower limb lymphoedema based on routinely collected QOL scores or a history of hospital admissions with related infection were invited to participate. QOL was assessed using the EORTC QLQ-C30 Version 3.0 and a supplementary gynaecological cancer-specific lymphoedema questionnaire. Home compression therapy was introduced not sooner than 3 months after primary cancer treatment. All patients applied compression treatment for at least one hour per day. Descriptive statistics and Wilcoxon signed-rank test were applied. A p-value < 0.05 was considered statistically significant.

Results

All participants’ functional and symptom scores improved with compression therapy with the exception of sexual function.

Conclusions

Self-management with pneumatic compression devices at home is a useful adjunct in the management of severe lymphoedema. Our preliminary experience showed a substantial improvement in most QOL parameters. We cannot say if domiciliary treatment with this compression device would have broader application or a role in primary or secondary prevention of lymphoedema if introduced at an earlier stage.

Accuracy, Sensitivity, and Specificity of the LLIS and ULL27 in Detecting Breast Cancer-Related Lymphedema

INTRODUCTION

Breast cancer-related lymphedema occurs in up to 30% of women following axillary lymph node dissection (ALND) and less commonly following sentinel lymph node biopsy. To quantify disability in these patients, patient-reported outcome measures (PROMs) have proven useful; however, given the overlap of symptoms between ALND and lymphedema, examination of their accuracy, sensitivity, and specificity in detecting lymphedema in breast cancer patients undergoing ALND is needed.

METHODS

The Lymphedema Life Impact Scale (LLIS) and the Upper Limb Lymphedema 27 scale (ULL27) were administered to patients who had undergone ALND at least 2 years prior and either did or did not develop lymphedema. Survey responses and the degree of disability were compared to generate receiver operator characteristic (ROC) curves, and the sensitivity and specificity of PROMs to diagnose lymphedema were analyzed.

RESULTS

Both PROMs were highly accurate, sensitive, and specific for detecting lymphedema. The LLIS had an accuracy of 97%, sensitivity of 100%, and specificity of 84.8% at a cutoff of ≥ 5.88 overall percent impairment score (higher scores indicate worse disability). The ULL27 had an accuracy of 93%, sensitivity of 88.6%, and specificity of 90.9% at a cutoff of ≤ 83.3 global score (lower scores indicate worse disability).

CONCLUSIONS

The LLIS and the ULL27 appear to be highly specific for lymphedema and capable of differentiating it from symptoms resulting from ALND alone. Our findings suggest that use of these questionnaires with a threshold may be effective for diagnosing lymphedema, potentially reducing the need for frequent clinic visits and time-consuming measurements.

Long-Term Outcomes of Lymph Node Transfer in Secondary Lymphedema and Its Correlation with Flap Characteristics

BACKGROUND

This retrospective study aimed to assess the impact of certain flap characteristics on long-term outcomes following microsurgical treatment in Breast Cancer-Related Lymphedema (BCRL) patients.

METHODS

Sixty-four out of 65 BCRL patients, guided by the "Selected Lymph Node" ("SeLyN") technique, underwent Vascularized Lymph Node Transfer (VLNT) between 2012 and 2018. According to their surface size, flaps were divided into small (<25 cm², n = 32) and large (>25 cm², n = 32). Twelve large and six small flaps were combined with free abdominally based breast reconstruction procedures. Lymphedema stage, flap size, vascular pedicle and number of lymph nodes (LNs) were analyzed in correlation with long-term Volume Differential Reduction (VDR).

RESULTS

At 36-month follow-up, no major complication was recorded in 64 cases; one flap failure was excluded from the study. Mean flap size was 27.4 cm², mean LNs/flap 3.3 and mean VDR 55.7%. Small and large flaps had 2.8 vs. 3.8 LNs/flap (p = 0.001), resulting in 49.6% vs. 61.8% VDR (p = 0.032), respectively. Lymphedema stage and vascular pedicle (SIEA or SCIA/SCIP) had no significant impact on VDR.

CONCLUSION

In our series, larger flaps included a higher number of functional LNs, directly associated with better outcomes as quantified by improved VDR.

Measurement Properties of the Lymphedema Life Impact Scale

Background: The updated Lymphedema Life Impact Scale (LLIS, version 2) has been widely used to evaluate the effect of lymphedema from the patient's perspective. We sought to assess its ability to accurately and efficiently measure lymphedema-related impact using modern psychometric techniques. Methods and Results: We collected a total of 1054 patient-reported outcome measure scores from 285 patients with upper extremity lymphedema and 65 patients with lower extremity lymphedema between 2016 and 2020. We first evaluated the relationship between the LLIS score, L-Dex score, and limb volume difference (LVD), and used classical test and item response theories to assess its psychometric performance. The LLIS score was only very weakly associated with LVD (r = 0.17, p < 0.001) and L-Dex score (r = 0.22, p < 0.001). The LLIS had acceptable dimensionality. Items 7 (affects body image) and 16 (affects proper fit of clothing/shoes) were locally dependent (Yen's Q3 = 0.45). Eight of the 17 items was interpreted differently between upper and lower limb lymphedema patients (pseudo R² ≥ 0.01). The scoring structure required correction for items 9 (affects intimate relations) and 12 (manages lymphedema). Removing items 18 (infection occurrence) and 7 resulted in substantially improved item response theory model fit (Tucker-Lewis index = 0.93, comparative fix index = 0.95, root mean square error of approximation = 0.07, and root means square of the residual = 0.06). The relationships between the LLIS and objective measures of lymphedema remained weak following modification (LVD; r = 0.13, p = 0.01, L-Dex; r = 0.26, p < 0.001). Conclusion: We were able to slightly improve the psychometric properties of the LLIS. However, these improvements did not rectify apparent issues with construct validity and both versions of the LLIS displayed a weak relationship with objective measures of lymphedema severity.

Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program

INTRODUCTION

Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay.

RESULTS

The study included 199 patients who had LVB (n = 43), VLNT (n = 145), or VLNT+LVB (n = 11). There was no difference in co-morbidities between the groups (p = 0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p = 0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p = 0.20). Operative time for LVB (305.4 min ± 186.7), VLNT (254 min ± 164.4), and VLNT+LVB (295.3 min ± 43.2) was not significantly different (p = 0.21).

CONCLUSIONS

Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.

Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review

BACKGROUND

Vascularized omental lymphatic transplant (VOLT) is an increasingly popular treatment of extremity lymphedema given its promising donor site. While the success of VOLT in the treatment of lymphedema has been reported previously, several questions remain.

AIM

To further elucidate appropriate use of VOLT in the treatment of lymphedema, specifically addressing patient selection, harvest technique, and operative methods.

METHODS AND RESULTS

A systematic review of VOLT for upper extremity lymphedema was performed. Of 115 yield studies, seven were included for analysis based on inclusion and exclusion criteria. Included studies demonstrated significant reductions in extremity circumference/volume (average volume reduction, 22.7%-39.5%) as well as subjective improvements using patient-reported outcomes. Though studies are heterogenous and limited, when analyzed in aggregate, suggest the efficacy of VOLT in lymphedema treatment.

CONCLUSION

This is the largest systematic review of VOLT to date. VOLT continues to show promise as a safe and efficacious surgical intervention for lymphedema in the upper extremity. Further studies are warranted to more definitively identify patients for whom this technique is appropriate as well as ideal harvest and inset technique.

Development and Psychometric Validation of a Patient-Reported Outcome Measure for Arm Lymphedema: The LYMPH-Q Upper Extremity Module

Background

A multiphased mixed-methods study was performed to develop and validate a comprehensive patient-reported outcome measure (PROM) for arm lymphedema in women with breast cancer (i.e., the LYMPH-Q Upper Extremity Module).

Methods

Qualitative interviews (January 2017 and June 2018) were performed with 15 women to elicit concepts specific to arm lymphedema after breast cancer treatment. Data were audio-recorded, transcribed, and coded. Scales were refined through cognitive interviews (October and Decemeber 2018) with 16 patients and input from 12 clinical experts. The scales were field-tested (October 2019 and January 2020) with an international sample of 3222 women in the United States and Denmark. Rasch measurement theory (RMT) analysis was used to examine reliability and validity.

Results

The qualitative phase resulted in six independently functioning scales that measure arm symptoms, function, appearance, psychological function, and satisfaction with information and with arm sleeves. In the RMT analysis, all items in each scale had ordered thresholds and nonsignificant chi-square p values. For all the scales, the reliability statistics with and without extremes for the Person Separation Index were 0.80 or higher, Cronbach’s alpha was 0.89 or higher, and the Intraclass Correlation Coefficients were 0.92 or higher. Lower (worse) scores on the LYMPH-Q Upper Extremity scales were associated with reporting of more severe arm swelling, an arm problem caused by cancer and/or its treatment, and wearing of an arm sleeve in the past 12 months.

Conclusions

The LYMPH-Q Upper Extremity Module can be used to measure outcomes that matter to women with upper extremity lymphedema. This new PROM was designed using a modern psychometric approach and, as such, can be used in research and in clinical care.

Single Center Retrospective Analysis of Cost and Payments for Lymphatic Surgery

Background

Insurance coverage for microsurgical lymphatic surgery continues to be sporadic, as the procedures continue to be labeled investigational. The objective of this study was to examine the typical payment patterns of our clinical practice for microsurgical lymphatic procedures.

Methods

We performed a single center, single surgeon retrospective case review for all lymphovenous bypass and vascularized lymph node transfer cases preformed from 2018 to 2020. We then queried the available financial data and calculated total charges, total paid by insurance, total variable cost (cost to the hospital), and the contribution margin (difference between the amount paid and variable cost). Descriptive statistics were then collected for each subgroup for analysis.

Results

Financial data were collected on 22 patients with 10 left-sided, 11 right-sided and one bilateral procedure performed. Seven procedures were done prophylactically, and 15 were done for existing lymphedema. An estimated 10 of 22 patients (45%) had Medicare, Medicaid, or Tricare, with the remaining having private insurance. We calculated an average cost of $48,516.73, with average payment of $10,818.68, average variable cost of $5,567.10, for a contribution margin of +$5251.58.

Conclusions

Lymphedema remains a common complication of surgery and a significant cost burden to patients and the healthcare system. Microsurgical procedures offer several advantages over medical therapy. In our practice, we were routinely reimbursed for both prophylactic and therapeutic procedures with positive contribution margins for the hospital and ratios similar to other surgeries. Despite the limitations of a small retrospective review, there is no similar published cost analysis data in the current literature.

Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema

BACKGROUND

A growing body of evidence supports the efficacy of surgical treatments for lymphedema. This study reports the outcomes of vascularized lymph node transplantation (VLNT) for the treatment of patients with lymphedema compared with maximal conservative treatment alone.

STUDY DESIGN

Consecutive patients undergoing VLNT to treat primary and secondary lymphedema affecting the upper or lower extremities were included. All patients were optimized preoperatively with conservative therapy. Demographic and treatment information was collected, and outcomes data were electronically captured prospectively; descriptive statistics were performed.

RESULTS

There were 134 patients included that had achieved maximal reductions by conservative therapy preoperatively. This series included jejunal mesenteric (n = 25), groin (n = 43), lateral thoracic (n = 31), omental or right gastroepiploic (n = 21), and submental (n = 14) VLN flaps. At 24 months postoperatively, there were significant reductions in limb volume change (mean [SD] 45.7% [8.7%]; p = 0.002) LDex score (mean [SD] 59.8% [8.7%]; p < 0.001), Lymphedema Life Impact Scale score (mean [SD] 61.6% [5.9]; p < 0.001), and cellulitis episodes (97.9%; p < 0.001). At 3 and 6 months postoperatively, limb volume change was significantly greater for the upper than the lower extremity, otherwise outcomes were similar. There were no flap losses and overall outcomes were similar between the different VLN flap types.

CONCLUSIONS

Treatment of lymphedema using VLNT resulted in progressive, significant reductions in limb volume, bioimpedance spectroscopy measurements of extracellular fluid, and episodes of cellulitis, with improved patient-reported outcomes and limb function measures compared with maximal conservative therapy alone. The complication rate was low and there were no significant outcomes differences between the VLNT types.

Lymphedema quality of life questionnaire (LYMQOL): cross-cultural adaptation and validation in Italian women with upper limb lymphedema after breast cancer

PURPOSE

There is growing interest in measures that assess upper-limb lymphedema after breast cancer. Since no validated Italian version of the Lymphedema Quality of Life Questionnaire for upper limbs (LYMQOL-UL) exists, we aimed to culturally adapt and validate an Italian version (LYMQOL-UL-IT) in order to allow its use in Italian patients.

MATERIALS AND METHODS

The LYMQOL-UL-IT was developed by means of forward-backward translation, review by an expert committee and a test of the pre-final version to evaluate its comprehensibility. The psychometric testing included reliability by internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficient, ICC_(2.1)), measurement error by calculating the minimum detectable change (MDC₉₅), construct validity by confirmatory factor analysis, and evaluation of a priori hypotheses about the correlations between the four LYMQOL-UL domains, single items of the LYMQOL-UL, and measures of health-related quality of life and pain intensity (Spearman's rank correlation coefficient).

RESULTS

The consensus-based version of LYMQOL-UL-IT was administered to 139 patients with upper-limb stable secondary iatrogenic lymphedema after breast cancer. The adapted questionnaire was well accepted as it was completed in less than 10 min, without missing answers or comprehension problems. Internal consistency was acceptable (α = 0.92-0.95). Test-retest reliability was good-to-excellent (ICC_(2.1) = 0.73-0.96). The MDC₉₅ for the four domains of the questionnaire was as follows: 0.64 scale points for Function, 0.40 for Appearance, 0.53 for Symptoms, and 0.81 for Mood. Factor analysis confirmed a 4-dimensional structure as originally conceived and the a priori hypotheses were met.

CONCLUSION

The LYMQOL-UL-IT is reliable, sensitive to change and valid in patients with upper-limb stable secondary iatrogenic lymphedema after breast cancer. It can be used for clinical and research purposes.Implications for rehabilitationLymphedema is a frequently unnoticed clinical condition that not only impacts physical functioning but often restricts the health-related quality of life in breast cancer survivors.The Italian version of the Lymphedema Quality of Life Questionnaire for upper limbs (LYMQOL-UL-IT) is reliable, sensitive to change and valid in patients with upper-limb lymphedema after breast cancer.The LYMQOL-UL-IT tool can be recommended for clinical and research purposes.

Patient-Reported Outcome Measures in Lymphedema: A Systematic Review and COSMIN Analysis

BACKGROUND

Lymphedema is a chronic and debilitating condition that affects many cancer survivors. Patient-reported outcome measures (PROMs) can give valuable insight into the impact of lymphedema on a patient's quality of life and can play an essential role in treatment decisions. This study aims to (1) identify PROMs used to assess health-related quality of life (HRQoL) in patients with lymphedema; and (2) assess the quality of the lymphedema-specific PROMs.

METHODS

We performed a systematic search to identify articles on lymphedema, quality of life, and PROMs. An overview was created of all PROMs used to assess HRQoL in patients with lymphedema. The methodological quality of the lymphedema-specific PROMs was assessed using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria.

RESULTS

A total of 235 articles met the inclusion criteria, of which 200 described studies using one or more PROMs as an outcome measure in patients with lymphedema. The other 35 studies described the development and/or validation of a lymphedema-specific PROM. The COSMIN assessment demonstrated that none of these PROMs met all quality standards for development.

CONCLUSION

The use of PROMs in lymphedema is increasing; however, based on our findings, we cannot fully support the use of any of the existing instruments. A well-developed lymphedema-specific PROM, based on patient input, is needed to gain better insight into the impact of this condition, and can be used to measure the effect of possible medical and surgical treatments.

Self-reported questionnaires for lymphoedema: a systematic review of measurement properties using COSMIN framework

INTRODUCTION

Lymphoedema may develop as a result of numerous genetic and traumatic causes; however, treatment for cancer is the most common cause of its development in more economically developed nations. This systematic review critically appraised, compared and summarised the measurement properties of lymphoedema-specific self-reported questionnaires (SRQs) measuring various patient-reported outcomes including quality of life (QOL), function, morbidity, and symptoms.

METHODS

Seven databases were searched to identify studies of the measurement properties of SRQs. Two review teams independently evaluated the quality of the individual studies using the risk of bias tool from the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). Measurement properties of the SRQs presented in the studies were then rated. Study level ratings were summarised for an SRQ if they were reported in multiple studies, and their overall quality of the evidence were then graded.

RESULTS

Forty articles, reporting on 19 SRQs were identified from 8615 records. The focus of the 19 SRQs included eight on QOL, four on symptoms, two on function, and two on impairment. The other three SRQs were on illness perception, self-efficacy, and patient-relevant treatment benefit, respectively. Eight and three SRQs were upper limb and lower limb-specific, respectively, whereas seven questionnaires were for both upper and lower limb lymphoedema. One SRQ was developed for head and neck lymphoedema. According to the COSMIN framework, none of the SRQs reviewed had sufficient evidence to support all nine measurement properties. In lower limb questionnaires, the LYMQOL-leg has sufficient content, structural, and construct validity as well as internal consistency and reliability. For upper limb lymphoedema questionnaires, the Lymph-ICF-UL had sufficient content and construct validity as well as reliability.

CONCLUSION

LYMQOL-leg SRQ is recommended with confidence for evaluation of QOL of people with lower limb lymphoedema while the Lymph-ICF-UL is recommended for evaluation of the QOL of the breast cancer-related lymphoedema with some confidence. In view of the high level of the indeterminate ratings of the measurement properties of the existing SRQs, further research is desirable.

Patient-reported outcomes following lymph reconstructive surgery in lower limb lymphedema: A systematic review of literature

OBJECTIVE

Lymphedema is a chronic, progressive and burdensome disease that is known to have a substantial impact on quality of life (QOL). Hence, the assessment of QOL is an important aspect of any study which seeks to evaluate outcomes after lymph reconstructive surgery. We therefore aimed to analyze currently available patient-reported outcome measurements (PROMS) for patients with lower limb lymphedema (LLL) with regard to their psychometric properties. Furthermore, we intended to evaluate the change in QOL in patient undergoing lymphovenous anastomosis (LVA) or vascularized lymph node transfer (VLNT).

METHODS

A literature research of four databases on studies that included PROMS for LLL was conducted. All selected studies were assessed for validity according Consensus-based Standards for the selection of Health Measurement Instruments. Studies that used the Lymph Quality of Life Measure for Limb Lymphedema (LYMQOL) after LVA and/or VLNT were included for quantitative analysis.

RESULTS

In total, 988 studies were screened, of which 30 studies were included in this review. We identified six validated PROMS to assess LLL. Of those, the LYMQOL was the most commonly used questionnaire. Based on the LYMQOL, a significant improvement of QOL in LLL was noted in all studies after reconstructive lymph surgery (LVA/VLNT) regardless of lymphedema etiology, stage, or time since diagnosis. On the basis of the Consensus-based Standards for the selection of Health Measurement Instruments criteria, the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema seems to be superior in terms of its psychometric properties.

CONCLUSIONS

A significant improvement in the QOL in patients with LLL after reconstructive lymph surgery can be observed. Future studies on reconstructive lymph surgery need to include both objective and congruent volume measurements, as well as data on QOL based a well-validated PROM such as the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema.

Outcomes following lymphaticovenous anastomosis (LVA) for 100 cases of lymphedema: results over 24-months follow-up

PURPOSE

Lymphedema is a debilitating condition that significantly affects patient's quality of life (QoL). The aim of this study was to assess the long-term outcomes after lymphaticovenous anastomosis (LVA) for extremity lymphedema.

METHODS

A single-center prospective study on upper and lower extremity lymphedema patients was performed. All LVA procedures were preceded by outpatient Indocyanine Green (ICG) lymphography. Quality of life measured by the Lymph-ICF was the primary outcome. Limb circumference, use of compression garments, and frequency of cellulitis episodes and manual lymphatic drainage (MLD) sessions were secondary outcomes.

RESULTS

One hundred consecutive patients, predominantly experiencing upper extremity lymphedema following breast cancer (n = 85), underwent a total of 132 LVAs. During a mean follow-up of 25 months, mean Lymph-ICF score significantly decreased from 43.9 preoperative to 30.6 postoperative, representing significant QoL improvement. Decrease in upper and lower limb circumference was observed in 52% of patients with a mean decrease of 6%. Overall mean circumference was not significantly different. Percentage of patients that could reduce compression garments in the upper and lower extremity group was 65% and 40%, respectively. Number of cellulitis episodes per year and MLD sessions per week showed a mean decrease of respectively 0.6 and 0.8 in the upper extremity and 0.4 and 1.0 in the lower extremity group.

CONCLUSIONS

LVA resulted in significant QoL improvement in upper and lower extremity lymphedema patients. Limb circumference did not significantly improve but good results concerning compression garments, cellulitis episodes, and MLD sessions were obtained. Additionally, a simple and patient-friendly method for outpatient ICG lymphography is presented.